Eating disorders can take many forms: the aspiring model who disappears to the bathroom after every meal; the college student who hoards junk food in his dorm room so he can binge in secret late at night; the gymnast who skips meals and time with her friends so she can keep training and keep her weight down. People can restrict their food, consume far more food than they need, avoid food, purge their calories, or literally starve themselves while surrounded by food. And no matter how disordered a person’s eating habits are, they still must face food every day. Calories are omnipresent and necessary for survival. So when proximity to food causes someone distress, it can be an incredibly painful, unrelenting experience.
Healthy, non-disordered eating involves consuming a balanced diet that incorporates a variety of foods, which you consume mindfully when you’re hungry and you stop consuming when you’re full. But honestly, how many people can testify that they do that every meal? We all experience disordered eating behaviors sometimes. Too much candy on Halloween. Severely restricting carbs when we’re trying to lose a few pounds. Late-night snacking when we’re not hungry. But people with feeding and eating disorders (FEDs) are distinguished by the significant emotional distress they feel around their chronically disrupted eating patterns.
It’s an especially tough psychological and behavioral condition to experience because not only can these individuals never escape from food, they can’t escape from their own bodies either. (Many eating disorders are characterized by a painful preoccupation with one’s body weight and shape.) So what can be done? In this Thriveworks guide to eating disorders, we take a compassionate look at conditions like anorexia nervosa and bulimia nervosa, then help light the way toward healthier minds and bodies. You can read the entire guide and come away with an in-depth overview of FEDs and disordered eating, or you can skip to the parts that are most relevant to your life. We look forward to helping you manage and overcome these complex behaviors–which is entirely possible with the right treatment.
What Are Eating Disorders?
According to the American Psychiatric Association, eating disorders are “behavioral conditions characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions”. Eating disorders are diagnosable psychiatric conditions that can severely impair someone’s quality of life. These mental illnesses can interfere with work, school, goals, and relationships. And they’re associated with medical complications like osteopenia and psychiatric comorbidities (simultaneous conditions) like major depression and anxiety disorders. They can also be life-threatening.
Bulimia nervosa, anorexia nervosa, and binge-eating disorder (BED) are the most common eating disorders in the US. An eating disorder can involve a fixation on weight, body image, and an internalized ideal of thinness, but it’s not necessary for diagnosis. Eating disorders can affect both children and adults, and both men and women, though some populations are more at risk than others of developing an eating disorder. And eating disorders can often hide in plain sight, affecting people who are clinically obese, people who have a body mass index (BMI) in a normal range, athletes who seem like the picture of health, and people who are underweight.
What Are the Signs of Eating Disorders?
An eating disorder can only be diagnosed by a qualified physician or mental health professional. There are, however, common signs and symptoms that may indicate someone should be evaluated in a clinical setting. For example:
- Negative body image
- Weight fluctuations or rapid weight loss
- Intense fear of gaining weight
- Baggy or layered clothes
- Persistent self-criticism regarding body parts, appearance, or weight (e.g., comments about feeling “fat”)
- Compulsive exercise (working out instead of spending time with others, working out when injured, working out for several hours a day, etc.)
- Obsession with dieting
- Food hoarding
- Avoiding places or social situations where food is present
- Discomfort with eating around other people
- Frequent excuses for skipping meals
- Using stimulants to suppress hunger
- Purging food by vomiting, using laxatives, or excessively exercising
- Severely restricting calories
- Denying oneself favorite foods
- Binge-eating regularly
- Extreme mood swings
Many of these behaviors can take place in secret, under the radar of family and friends. For example, if someone disappears to the bathroom after every meal they may be throwing up their food. People with eating disorders often deny that they have an issue that requires treatment.
Parents of young children (under 12 years old) should also be on the lookout for the following:
- Aversion to certain tastes and textures in food
- Worries about stomach aches
- Consumption of non-food substances like dirt, sand, ice, or hair
Someone with an eating disorder might display physical signs and suffer from associated medical conditions as well. For example, a person with anorexia nervosa might feel extremely cold and need to dress in many layers to stay warm. They may grow fine hairs on their body (lanugo). Women with anorexia may experience menstrual irregularities or their period may stop completely (amenorrhea). A person with bulimia might experience erosion of their tooth enamel or cuts on the top of their hands due to self-induced vomiting. Eating disorders can also show up in blood tests in the form of anemia or low potassium levels.
What Are the Different Types of Eating Disorders?
Mental health professionals like psychiatrists and eating disorder specialists classify feeding and eating disorders (FEDs) according to clinical guidelines laid out in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM-5 lists diagnostic criteria for the following disorders:
- Anorexia nervosa, which is characterized by self-starvation and an intense fear of gaining weight. A person with anorexia critically connects their body image to their self-view. Their body weight/BMI is lower than it should be for their physical health. The condition can be extremely dangerous if left untreated. Someone can be a restrictive type of anorexic or a binge-eating/purging type of anorexic.
- Bulimia nervosa, which is characterized by cycles of binge eating (eating without a sense of control over a discrete period of time) and purging (compensatory behaviors that might involve excessive exercise, self-induced vomiting, diuretics, laxatives, or fasting). Body shape and weight are also excessively important in the bulimic individual’s self-evaluation.
- Binge-eating disorder (BED), which is characterized by recurrent episodes of binge eating, which cause the individual marked distress.
- Avoidant-restrictive food intake disorder (ARFID), which is characterized by someone’s failure to meet their own nutritional needs due to an aversion to sensory characteristics of food. They are underweight or malnourished.
- Pica, which is characterized by the consumption of non-foods like dirt and sand when developmental immaturity can’t account for the behavior.
- Rumination disorder, which is characterized by the repeated regurgitation of food.
- Other specified FED, which includes atypical anorexia nervosa, purging disorder, night eating syndrome, and bulimia or binge-eating with low frequency and/or limited duration.
- Unspecified FED, which is an eating disorder that causes impairment in major areas of functioning but doesn’t meet the DSM-5 criteria for other FEDs.
How Do Eating Disorders Start?
The musician Taylor Swift opened up about her disordered eating habits in the documentary “Miss Americana,” saying that she would “starve a little bit” whenever she felt “fat”. In later interviews, she stated that this punitive cycle of eating behavior was a response to alternating social praise and criticism about her weight.
Taylor Swift isn’t alone in internalizing society’s expectations about how our bodies should look. People with anorexia or bulimia may start by becoming preoccupied with their weight and conforming to magazine-perfect ideals, then their behaviors escalate until they reach pathological territory. You can get caught up in a cycle of positive feedback when people congratulate you on losing weight, and self-hatred when you look bloated. Your behaviors may be reinforced by a feeling of control. Before you know it your entire sense of self-worth is tied up in how much you’ve eaten and how your body looks from day to day.
But the onset of every eating disorder is specific to the individual. There’s no one, clearly delineated path to developing an eating disorder. But people who begin to place major importance on their body weight may risk escalation of their dietary behaviors. Or people may begin a “health kick” that becomes more intense and emotionally involved. Symptoms begin to creep further and further into your life, resulting in increased distress and maladaptive behaviors.
Many people with eating disorders use their food behaviors as a way of coping with negative emotions. For example, someone who feels lonely or depressed may binge on food in order to quell those feelings in the short-term. Then they feel depressed about their lack of control, which leads to another binge. Before they know it, they’ve fallen into a full-fledged binge-eating disorder.
What Causes Eating Disorders?
There’s no single cause of eating disorders, though many blame society’s pressures surrounding peoples’ weight, especially unachievable ideals about the shape of women’s bodies, for anorexia and bulimia. Environmental and social factors can certainly play a role in how a person perceives themselves.
In addition to these pressures, there are also psychological and biological factors that can cause disordered eating and eating disorders. For example, eating disorders are associated with psychiatric conditions like depression and anxiety. Certain personality traits like perfectionism, extreme compliance, and neuroticism have been associated with anorexia nervosa. And neurochemicals can influence hunger and appetite. There’s also a genetic component to eating disorders, accounting for 32-72% of risk.
How Common Are Eating Disorders?
A 2019 study in the Journal of the American Medical Association (JAMA) estimated the lifetime prevalence of eating disorders at 14.3% for men and 19.7% for women by age 40. Rates are even higher among sexual minority adults. According to JAMA, most patients only have a single ED episode, but women are more likely to experience multiple episodes.
Here’s a further breakdown of eating disorder prevalence by type:
- According to data from the National Institute of Health, the overall prevalence of binge-eating disorder (BED) in US adults (age 18 and older) is 1.2%. It’s twice as prevalent among females as males. Of the adults with BED, 18.5% experience severe impairment.
- The lifetime prevalence of anorexia nervosa in adults is 0.6%, and the disorder is three times more prevalent among females than males. Some studies conclude that the ratio of female to male anorexia is 10:1.
- The overall prevalence of bulimia nervosa is 0.3%, and the disorder is five times as prevalent among females than males.
- In US adolescents (ages 13 to 18 years), the lifetime prevalence of the eating disorders anorexia, bulimia, and BED is 2.7%. Eating disorders are more than twice as prevalent among girls as boys.
Eating Disorders Are Most Likely to Develop in Which Stage of Life?
Eating disorders can occur at almost any time during the lifespan, but they primarily occur in young adulthood. According to JAMA, almost all first-time cases (95%) occur by age 25. The highest mean prevalence among men and women occurs at approximately age 21. Though according to the NIH, the median age of BED onset is 21 versus 18 for both bulimia nervosa and anorexia nervosa.
How Are Eating Disorders Diagnosed?
Eating disorders are typically diagnosed by the frequency of behaviors and the emotional distress associated with the behaviors. For example, to diagnose bulimia nervosa, psychiatrists follow guidelines laid out in the DSM-5. Some of these diagnostic features were updated from the DSM-4. For example, now an individual with bulimia must:
- Have recurrent episodes of binge-eating, where they consume excessive calories in a discrete, 2-hour period and feel that they lack control over the amount of food they’re consuming.
- Exhibit recurrent compensatory behaviors to make up for the food consumption. For example, they might induce vomiting, exercise excessively, or take laxatives in an effort to purge the calories they binged.
- Binge and purge at least once a week for 3 months.
- Evaluate themselves based on body shape and weight.
Bulimia can be assessed as mild (1-3 episodes/week), moderate (4-7 episodes/week), severe (8-13 episodes/week), or extreme (14+ episodes/week).
Other eating disorders are diagnosed according to similarly stringent criteria. But because so many eating behaviors take place in secret and because individuals may be in denial about their issue, it could take years before someone actively seeks treatment for their disorder. Disorders tend to be all-consuming, severely impairing someone’s functionalities. Food obsessions can impact sleep, focus, energy, and much more.
How Do You Treat Eating Disorders?
There are a number of effective, evidence-based treatments for eating disorders. Psycho-behavioral talk therapy with a licensed professional is usually the first-line treatment. Many studies have been conducted on the efficacy of cognitive behavioral therapy (CBT) in treating anorexia nervosa, bulimia nervosa, and binge-eating disorder (BED). In severe cases, an eating disorders-informed clinician can help assemble a multidisciplinary team of specialists to assist in treatment. This team might include a family doctor, a dietician, and a family therapist. Family support is especially crucial to recovery and remission from eating disorders, especially for adolescents and teenagers.
If someone with an eating disorder like anorexia cannot maintain a viable weight, they may need to be treated in a hospital specialist program. Inpatient programs can ensure that someone receives the calories they need while learning coping skills, getting CBT, and even taking prescription medication (antidepressants or mood stabilizers) associated with psychiatric conditions like depression and anxiety.
How Do You Prevent Eating Disorders?
There’s no grand clinical consensus on how to prevent eating disorders, but mental health professionals agree on some risk factors that can influence who might develop an eating disorder. For example:
- Evidence of dieting, unsuccessful dieting, and dietary restraint
- Unhealthy weight loss behaviors
- Gender (women and girls are more at risk)
- Puberty onset
- Social and cultural emphasis on being thin
- Race and socioeconomic status
- Personality traits
- Psychiatric comorbidities
- Negative affect
- Higher body weight
- Body dissatisfaction
- Family history
By recognizing these risk factors, family members and friends can intervene early with compassionate support. There are also certain activities that can increase a person’s risk of developing an eating disorder. For example, elite athletes (both male and female) are especially vulnerable and may benefit from targeted interventions.
Children and adolescents can universally learn about effective weight management strategies involving diet, physical activity, cultural awareness, and behavior change through a healthy weight regulation (HWR) model. The Stoplight Diet for Children has been particularly successful. A self-esteem/social competence (SESC) prevention model focuses on empowerment and confidence. Parents can participate in these interventions through family-based behavior modification programs. Lastly, cognitive-behavior modification (CBM) programs can help teach children problem-solving skills and emotional regulation.
How Can You Help People with Eating Disorders?
To help someone with an eating disorder, you must educate yourself first. Learn the warning signs and risk factors, and remember that there are usually powerful emotions involved in eating disorders. You can’t just tell someone they’re behaving irrationally, for many people use unhealthy eating patterns as a (maladaptive) coping mechanism. Don’t minimize their experience. In addition, you can do the following:
- Respectfully explain your concerns
- Express your love
- Don’t broach the subject when you’re upset
- Gently suggest alternative coping strategies for difficult emotions
- Don’t bring up the eating disorder during meals, which may already be stressful enough for the individual
- Help them improve their body image
- Create a resource list of therapists and clinics that specialize in eating disorders
- Continue to provide support and compassion throughout treatment
- Participate in family therapy